Staffing for Safe and Effective Care

Transcription

1 Staffing for Safe and Effective Care Nursing on the Brink POLICY REPORT

2 STAFFING FOR SAFE AND EFFECTIVE CARE Acknowledgements Project Team Authored by: Antonia Borneo Significant contributions from: Philip Ball, Androniki Bayliss, Lara Carmona, Rita Devlin, Lizzie Dowd, Nigel Downes, Mirka Ferdosian, Sian Kiely, Gerry O Dwyer, Wendy Preston, Emily Romero-Wiltshire, Emma Selim, Janice Smyth, Maria Trewern, Lisa Turnbull and Glenn Turp. RCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance. Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN 2018 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. 2

3 ROYAL COLLEGE OF NURSING Contents 1. Introduction 4 2. RCN campaigning across the UK 6 3. Engagement with our members 7 4. Hearing more from frontline nursing staff 9 Appendix 1 - RCN Statement: nurse staffing for safe and effective care 13 Appendix 2 - UK perceptions and wellbeing questions by setting 14 Appendix 3 - Free text responses to perception and wellbeing questions 19 3

4 STAFFING FOR SAFE AND EFFECTIVE CARE 1. Introduction At Congress 2017, the membership of the Royal College of Nursing (RCN) raised the alarm on the growing nursing workforce shortages across the UK, and their concern at the implications on patient safety. We received a clear mandate from members to lobby for clear accountability for ensuring the provision of an adequate supply of registered nurses and nursing support staff, throughout the health and social care system to meet the needs of the population, in every country in the UK. Having the right number of registered nurses and nursing support staff with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for patients and clients. The planning and delivery of nurse staffing for safe and effective care is necessarily complex due to the constantly changing circumstances and associated complexity and acuity of individual patients and clients. In calling for clear accountability through legislation and guidance, language is incredibly important, and shared understanding is critical. The RCN has therefore undertaken extensive engagement with members, RCN Boards, and nursing workforce experts, which we set out in this report. The outcome of this engagement is a set of RCN principles which provide high-level objectives which most meaningfully represent what we need to achieve on staffing for safe and effective care, though legislation, statutory instruments and guidance, and sufficient funding, in every country in the UK. I ve only been qualified seven months and I ve never worked a shift where the staffing levels are adequate. 4

5 ROYAL COLLEGE OF NURSING RCN principles for staffing for safe and effective care Nurse staffing for safe and effective care is dependent upon the following, and legislating to secure nurse staffing for safe and effective care must address each of these areas: 1 A governance framework that details responsibility and accountability for ensuring an adequate supply of registered nurses and nursing support staff is available throughout the health and social care system to meet the needs of the population. Responsibility and accountability throughout the health and social care system will be made explicit and transparent as they relate to Government Departments, commissioners of services, providers of services and regulators (those responsible for providing system assurance about quality and safety of patient care). 2 Ensuring that the right number of registered nurses and nursing support staff with the right knowledge, skills and experience are in the right place at the right time. Any determination about nurse staffing must be informed by legislation, Nursing and Midwifery Council requirements, national regional and local policy, research evidence, professional guidance, patient numbers, complexity and acuity, the care environment and professional judgement. Financial resources and expenditure must be in place to fully fund and support the delivery of workforce plans and the provision of nurse staffing for safe and effective care. 4 Workforce plans developed at national, regional and local level to support strategic objectives as detailed in the workforce strategy. Responsibility and accountability for the development, approval and implementation of workforce plans and monitoring of workforce against approved plans will be specified. There will be transparency through consistently recorded and publicly reported data across health and care settings on the actual numbers and skill mix of nursing staff. 5 Robust commissioning arrangements for pre- and post-registration education and development. Any commissioning arrangement must be underpinned by credible assessment of supply and demand for the nursing workforce. Responsibility and accountability for determining the requirement for education and development programmes, at pre- and postregistration level, to meet the requirements detailed in workforce plans will be specified. The UK nursing workforce remains in a critical state. There are fewer nurses on the UK-wide register this year than both previous years: there are now 2,278 fewer nurses than For a second year in a row there are more nurses and midwives leaving the profession than joining. 3 A workforce strategy addressing national, regional and local levels, detailing the overall aim, strategic objectives and required actions. Clearly stated vision at Chief Nursing Officer level as to how nursing will contribute to population health and address the population health needs and objectives to be achieved to ensure that the vision is translated into action at all levels in the health and social care system will be specified. 5

6 STAFFING FOR SAFE AND EFFECTIVE CARE 2. RCN campaigning across the UK The numbers of nursing students are not growing quickly enough across the UK as a whole. Legislation on staffing currently is in different stages of development in Wales and Scotland. In Wales the Nurse Staffing Levels Act received Royal Assent in March 2016, but the RCN campaign in Wales hasn t stopped there. Statutory guidance explaining how to implement the Act was issued to NHS Wales in November 2017 and we have worked hard to make sure that protected time for educational mentors and the supernumerary status of the ward sister/charge nurse was protected. The Act has fully come into force in April 2018 and RCN activists in Wales are now busy scrutinising the Health Boards and challenging decisions locally. The RCN in Wales is also calling for scrutiny of the implementation in the National Assembly. At the same time the Welsh Government has promised to extend the Act to cover new areas of nursing including paediatrics, mental health and community nursing so this is a key policy influencing area for the RCN in Wales. The First Minister for Scotland pledged to introduce safe staffing legislation at the RCN Congress in Glasgow in Since then the RCN has campaigned hard to influence the shape of the Scottish Government s proposed Bill so that it will genuinely address the experiences and concerns which our members have shared around staffing for safe and effective care across settings. The RCN has yet to see the full text of the Bill, but from discussion with civil servants we understand that some, but not all, of our concerns have been addressed to date. The Scottish Bill is due to be published before the end of June 2018, with parliamentary debate starting in the autumn. The RCN in Scotland is now working to engage with members, partners and the public to ensure MSPs understand the positive impact robust staffing legislation could have on patient care and staff wellbeing, and to build alliances on possible amendments to the Bill. In England and Northern Ireland, there are currently no plans to introduce legislation related to staffing levels and workforce to deliver safe and effective care for public safety and protection. Northern Ireland continues to be affected by an absence of government. This autumn, the RCN in England and Northern Ireland will be campaigning to drive public and political support for legislation. Newly qualified staff often cry during shifts due to stress and a fear of compromising patient care. I genuinly feel like I ve been put in positions when my pin is at risk due to unsafe staffing levels. 6

7 ROYAL COLLEGE OF NURSING 3. Engagement with our members It is more important than ever to hear directly from the frontline, across health and care services in the UK, about the reality of current staffing levels and the impact that this has on people using health and care services, and on staff. Since our annual Congress in 2017, we have carried out a range of engagement activity with RCN members, to develop our understanding of the issues related to staffing for safe and effective care which must be addressed by legislation and other relevant policies and action. RCN representatives and stewards In June 2017, we held a workshop with more than 100 RCN learning representatives, safety representatives and stewards who provide employment-related support to frontline staff in health and care workplaces across the UK. There was unanimous agreement that many individual employment relations cases are linked to the pressures on nursing staff to provide care and treatment within services that are experiencing workforce shortages. Participants expressed consistent views that registered nurses carry disproportionate risk for low staffing levels within services. This is exacerbated by the fact that Boards of providers of health and care services are not held to account. UK nursing workforce experts In July 2017, we convened an external expert reference group of academics and practitioners to support our work. This group meets regularly, providing expert guidance and inputs into our developing programme of activity. Their expertise and guidance is of significant value for the RCN in developing our understanding and positioning on complex issues. In December 2017, we held a workshop to establish a set of principles to underpin legislation and other policy measures in every country in the UK. These were further refined and agreed by the RCN Professional Nursing Committee before returning to the Expert Reference Group in April These principles will be the basis of RCN lobbying in each country in the UK, which is already well underway in Wales and Scotland. Registered nurse members In November 2017, we held focus groups for registered nurses (Bands 5-7) in regions across the UK. We asked participants to tell us what staffing for safe and effective care means to them, what support employers should provide to ensure safe staffing levels, and what needs to be in place to address any concerns staff might have. Participants described staffing for safe and effective care as: Patient centred, focused on quality and outcomes, taking into account needs of patients and rising levels of demand, including supporting families and loved ones. Staff have access to training, including mandatory training, as well as continuing professional development. Staff are supported with the right level of registered nurse supervision to provide safe and effective care. Participants said that health and care employers need to ensure the following are in place to make this possible: Right staffing to meet patients needs, including the right skill mix, including proportion of registered nurses to nursing support staff and adequate specialist skills. Also no staff deployed outside the boundaries of their role or scope of practice, and ensuring that registered nurses don t have to spend excessive or disproportionate time on nonnursing duties so that sufficient times is available for people to provide patient care. Accountability at Board level in any health and care employer, with supportive managers and leadership, responding to concerns, demonstrating efficient recruitment and retention systems, with clear accountability for admitting, transferring or discharging individual patients. 7

8 STAFFING FOR SAFE AND EFFECTIVE CARE Transparent decision making in workforce planning and management, including data/ incident reporting and application of learning, open communication between leadership and staff, decisions focused on patients needs and not driven by finance, service offer reviewed, decisions about nurses and nursing underpinned by the NMC s Code of Practice. Local protocols and guidance to support nurses to raise concerns by staff in all settings, and to support professional accountability, appropriate use of bank and agency staff with the right competencies, and appropriate movement of staff between specialist services to cover staffing gaps. Staff are valued by their employer, through measures such as flexible working, promotion of non-bullying culture, access to occupational health and subsidised health/wellbeing services including counselling, leadership highlighting success, encouragement and support for innovation, time allowed for debriefs at end of shift for learning and emotional support. RCN Boards In November 2017, we presented to RCN Boards across the UK and sought their views on priorities related to staffing for safe and effective care. The resounding consensus was that staffing levels and skills mix had reached crisis point, and that senior nurses and their employers (health and care provider organisations) were facing significant decision-making pressures regarding staffing of services for safe and effective care. Directors of Nursing in the UK In December 2017, we invited a number of senior nurses from across the UK to meet, and a position about the current workforce situation was developed in partnership with those who participated. This position reinforces and further develops the RCN s call for legislation to secure accountability for staffing for safe and effective care at national Government level in each country, as well as at corporate level locally. See Appendix 1. Over the last 30 years in the NHS, I have seen a rapid decline in nursing numbers and this scares me. At that time the view from our Boards was that health and care providers must have shared corporate accountability within any organisation for ensuring first and foremost that services are safe, and that reviewing the services provided is necessary if this cannot be guaranteed due to workforce shortages. RCN Boards also agreed that it is imperative that governments across the UK hold formal accountability for growing the workforce supply to meet the health and care needs of our populations. 8

9 ROYAL COLLEGE OF NURSING 4. Hearing more from frontline nursing staff In May 2017, at our annual Congress, we launched a survey asking frontline nursing staff to report their experiences and perceptions in their last working shift or day working in health and care settings across the UK. In September 2017, we published Safe and Effective Staffing: Nursing Against the Odds, which published findings from 30,865 responses. Our key findings included: 55% of respondents reported a shortfall in planned staffing of one or more registered nurses on their last shift (58% for NHS providers and 25% for independent providers). 41% of all shifts reported being short of one or more health care support workers. 20% of the registered nurses across the 30,000 shifts were temporary staff and 28% of health care support workers were temporary staff. 36% said that due to a lack of time they had to leave necessary patient care undone. Over half (53%) said care was compromised on their last shift. 53% felt upset/sad that they could not provide the level of care they wanted. 44% said no action was taken when they raised concerns about staffing levels or compromised care. 65% said they worked additional time, with on average almost one hour of extra work (53 minutes). 93% who worked extra unplanned time in NHS providers were not paid for this time. For non- NHS providers, the figure is 76%. Based on survey findings, our conservative estimate was that the additional unpaid time worked by registered nurses in the NHS across the UK equates to 396million annually. This survey provided valuable information on the realities of staffing levels and skill mix, directly from the frontline. It became undeniable that staffing levels have detrimental impact on patient care, and on staff. Responses to some of the questions revealed significant concern around particular types of impact of insufficient staffing levels on the provision of safe and effective care for patients, and on staff (see Appendix 2). We have since further investigated the additional information that 17,819 respondents provided about the impact of staffing levels on patients and staff, through additional free text responses to the survey (see Appendix 3). Most frequently used words were identified, as well as words associated with them. This was used as a basis to search for responses using these or similar words, and from these responses, themes appearing repeatedly and consistently were identified. For the first time, we present here the most commonly reported themes: Care undone (missed care) due to lack of time More than a third (36%) of respondents agreed or strongly agreed with the statement that due to lack of time related to shortages in the nursing workforce, necessary care had gone undone. This was highest at 45% in prison settings and 37% in hospitals. Due to lack of time created by workforce shortages, staff described patients having to wait for treatment and care, including having access to toilet and washing, pain relief, and care such as action to prevent bed sores, ulcers and infections. Due to inadequate staffing the observation of patients and their condition and recording of vital signs is not being carried out to the level required. Staff coming on shift are asked to deliver care that has been left undone. Some staff perceive that some managers view care left undone as a lack of competence on the part of staff. Respondents reported a particular concern that care is becoming task-based, rather than being able to deliver the full range of care required by patients, and that they wish to provide, including treatment, emotional support, information and support for individual self-management. Some respondents were particularly concerned about being unable to spend enough time to listen to patients or their families, take time to give them information, including supporting patients to receive important news, or during end-of-life care. Some respondents even reported being 9

10 STAFFING FOR SAFE AND EFFECTIVE CARE unable to provide a good death due to staffing shortages and lack of time to be able to spend with individual patients. In community settings, which include providing nursing care in people s homes, and in primary care services, schools or hospices, caseloads and visiting schedules are described as unrealistic due to the lack of staff to carry out visits. Respondents described how this resulted in cancelled visits because there weren t enough nursing staff to keep schedules, not allowing for travel time or adequate time with each patient. They reported having to prioritise only patients with urgent and complex needs, as opposed to the wider range of preventative and rehabilitative care that others are meant to be receiving. Some responses said that having to make these decisions because of lack of staff, and unrealistic caseloads and schedules, meant they are not providing the level of care they want to, and that they felt they are letting down people who are relying on them. The impact nursing staff described is that patients and their families understandably become frustrated, and may complain about their care. Staff reported feeling unable to provide care to the quality they want, describing feeling guilty and apologetic, and reported a negative impact on morale. Staff also reported lack of time to take breaks whilst working, as well as regularly working extra time, typically unpaid. Too much time spent on non-nursing duties More than half of respondents (55%) agreed or strongly agreed specifically that they were spending too much time on non-nursing duties, given the impact of workforce shortages on meeting patient needs. This was highest at 58% in both care homes and in communitybased services. Respondents described having to make difficult choices when there are shortages of registered nurses, between completing paperwork and providing care and treatment, as well as an inadequate skill mix of nursing staff to provide required care and treatment. They also report further impact when the registered nurses on duty are bank or agency staff who do not know the client group and are not familiar with I am not sure if I want to stay in nursing. I feel the care I give is compromised by trying to complete specific tasks which are more concerned with audit and performance rather than care of the patient. The paperwork is onerous, repetitive and does not facilitate care planning. It is recognised that the staffing levels are inadequate and our senior charge nurse is trying to address this with management with some success. treatment and care required. This included times when there were high levels of agency staff who were often unable to access IT systems to update files because the organisation s system could not facilitate access by non-permanent staff. Respondents described this approach as potentially unsafe, as well-kept records and notes are essential for safe and effective care. They said there was greater room for error due to having to rush, and that non-nursing duties might not be completed. Some respondents reported working extra unpaid time, specifically to finish paperwork. Respondents described feeling stressed by the volume of work, and the difficulties balancing clinical and management responsibilities because there aren t enough nursing staff. Time to support relatives and those of importance to patients 39% of all respondents disagreed or strongly disagreed that they had enough time to support patients relatives and loved ones. Examples described often related to end-of-life care, as well care and treatment in communitybased settings and in people s homes, including self-care. There was a clear view that respondents wanted to spend time with relatives, and to provide information and support, but simply did not have the time to due to workforce shortages and the level of demand. Some respondents 10

11 ROYAL COLLEGE OF NURSING reported being affected when relatives were frustrated that their needs were not being fully met, and dissatisfied with the service there were receiving. This experience was described as being particularly upsetting, leading to low morale in nursing staff, because this is an aspect of care many are very motivated to provide, but were unable to due to lack of nursing staff. Concern about skill mix of nursing staff Over a third (35%) of respondents said they were concerned about the combinations of people and skills, including registered and specialist nurses, and support staff, providing care and treatment (referred to as skill mix ). The highest level of concern about skill mix was reported in prisons and police settings at 49%, and second highest in emergency care at 48%. Respondents consistently made reference to issues with the numbers of nursing staff at different levels of skill, particularly inadequate numbers of registered nurses to support staff, as a result of shortages. Respondents pointed out that staffing levels are as much about skill and specialism as they are about numbers of nursing staff, and that skill mix was also affected when staff are moved between different clinial services to provide cover where there aren t enough people. They described how these decisions might be taken by managers who did not have expertise in the specialist skills required. Respondents described too few registered nurses in proportion to nursing support staff, putting pressure on all involved. Registered nurses, for example, are responsible for aspects of assessment and treatment which support staff are unable to provide, meaning that they have a large volume of patients for whom only they can fulfil certain duties. Poor skill mix was ultimately described as potentially unsafe due to difficulty providing the full range of treatment and care when there weren t the right numbers of people with the right skills in the right place at the right time. Respondents described feeling at risk as a result of this. The skill mix in terms of the right numbers of staff able to fulfil the right duties is also affected if a service is reliant on too great a proportion of agency staff, who may not be familiar with the patient s care or have access to the IT system, meaning that regular staff are affected by needing to provide support to them in in carrying out these duties. Student respondents described being inappropriately counted within planned and reported staffing levels. They described being expected to fulfil the role of a health care support worker, when they should instead be protected and supported to gain nursing knowledge and develop nursing skills on their placement, and not be counted in the numbers of nursing staff providing care (supernumerary). Just over one in four (27%) respondents also agreed or strongly agreed that they were concerned about support staff being expected to perform duties of registered staff without the appropriate supervision. This was highest in prisons and police settings at 37% agreeing or strongly agreeing. All settings reported a high level of concern regarding employers expecting nursing support staff to carry out care and treatment at the level of responsibility of a registered nurse, which is not appropriate or safe. Particularly in acute services, both registered nurses and support staff respondents reported concern that employers expect support staff to work outside of the boundaries of their role. Support staff described being given responsibility and allocated duties beyond their level of knowledge and skill. They also said they were unable to seek the support and supervision they require to provide care safely, as registered nurses did not have time to provide this, due to workforce shortages. Prison and police services described support staff responsible for emergency care for entire prison wings on night shifts, and in some cases, emergency care staff also being required to cover non-emergency treatment, which they described as unmanageable. Some senior nurse respondents with management duties said that their supervisory hours were not protected, and that they should not have been counted in the numbers of staff providing care and treatment, but were in fact counted and expected to fulfil unrealistic workload. They described being unable to take 11

12 STAFFING FOR SAFE AND EFFECTIVE CARE a break during their shift, due to supervising a large number of support staff who, unlike registered nurses, are not able to carry out assessments of a patient s condition or their response to care and treatment. In this scenario, registered nurse respondents said it is not possible to provide thorough assessments of what patients in health and care services needed. Are staffing level concerns addressed? Only 37% of respondents said that action was taken to try to address concerns they had raised if there were not enough staff and patient care was compromised. This was particularly an issue in prison and police settings, with only 26% saying action was taken. There was a consistent reported experience of the concerns of nursing staff not being acknowledged, listened to, or addressed by employers. Respondents consistently reported that their experience was that of employer organisations failing to take action to resolve staffing shortages, citing budget constraints or lack of available workforce to recruit into services. They also said that employers did not address the negative impact on patient care or on staff, holding nurse managers responsible for finding cover, and for providing good quality care with too few staff, or with an inadequate skill mix. Respondents also reported attempts by managers to mask staff shortages by inappropriately including students on learning placements, and supernumerary senior nurses, in the staffing numbers counted and reported internally. Respondents reported that employers expected staff to work extra time past scheduled shifts, as well as go without breaks or annual leave. This experience was reported as the norm, leading to people being absent from work due to work related stress and exhaustion, and colleagues starting to leave their jobs. Some respondents also felt that raising concerns put them under scrutiny themselves, with potential risk of repercussions for having done so. Morale of nursing staff 44% of respondents agreed or agreed strongly that they have been demoralised by the impact of short staffing. Agreement with this statement was highest in urgent and emergency care at 50%, and then prison and police settings, at 49%. Respondents described being affected by being unable to provide the quality of care they wish to, due to staffing levels, and by feeling undervalued as they and their colleagues struggled to cope with ever more difficult working conditions as result of shortages. The experiences described were that of being under constant pressure to maintain standards of quality and safety, and feeling at risk professionally. Recently graduated nurses reported feeling overwhelmed, with some respondents considering leaving their job, and descriptions of colleagues leaving due to the pressures caused by staffing shortages. Respondents consistently described feeling regularly stressed, exhausted and upset by these experiences, and not well supported by their employer. I now find myself regularly feeling that I ve not been able to provide safe - let alone quality - care to my patients. This is completely inappropriate and unacceptable, and to be put in a position where I feel as though I am harming patients due to a systemic lack of concern for safe staffing levels is pushing me towards seriously considering a new career. This must stop. This is scandalous, cruel to both patients and staff and quite frankly dangerous! 12

13 ROYAL COLLEGE OF NURSING Appendix 1 - RCN Statement: nurse staffing for safe and effective care The Royal College of Nursing and senior nurse members from across the UK have worked together to act on the concerns raised by of frontline staff about nurse staffing for the provision of for safe and effective care in all health and care settings. The following points within this statement clearly identify actions required to address the professions concerns. The RCN will lobby for legislation and supporting statutory instruments to be in place for each country of the UK that clearly demonstrates specific accountability within each health and care system to ensure that nurse staffing is appropriate to provide safe and effective care. 1. Nurse staffing that provides for safe and effective care enshrined in law is appropriate and required within each country of the UK. 2. Legislation should be devised to specify accountability for staffing across health and social care systems, in a manner that addresses supply and demand in the nursing workforce. 3. Government, national and local system accountability for staffing must be specified in law, including the requirement for health and social care systems to have credible and robust workforce strategy, and data-driven workforce planning. 4. Funding should be established, developed and follow models of safe and effective care. 5. There must be corporate accountability for staffing at Board level (national, regional and local) of public and independent organisations, in all health and care settings. Executive Directors of Nursing are responsible and accountable for the advice that they give to Boards, and Boards are responsible and accountable for the actions they do or do not take as a result of that advice. 6. When determining safe, legislation must address ensuring the right numbers of registered nurses with the right knowledge, skills and experience in the right place at the right time. 7. Legislation and statutory instruments for staffing should provide for any setting in which nursing care is commissioned or delivered, to ensure the right numbers of registered nurses with the right knowledge, skills and experience, supported by appropriate nursing support staff, are in the right place at the right time. 8. Clear guidance should be incorporated into statutory instruments which ensures that professional judgement, and patient acuity are provided for in each health and care system, alongside the quality, experience and outcomes of patient care. 9. Sustained investment in education, training and professional development are essential for the provision of the right numbers of registered nurses with the right knowledge, skills, competencies and experience to provide safe and effective care. 13

14 STAFFING FOR SAFE AND EFFECTIVE CARE Appendix 2 - UK perceptions and wellbeing questions by setting I had enough time to provide the level of care I would like (n. 27, 584) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 7% 7% 12% 7% 9% 10% 8% Agree 24% 23% 29% 23% 25% 29% 23% Neither agree nor disagree 18% 16% 18% 13% 15% 18% 16% Disagree 37% 40% 30% 38% 37% 35% 39% Strongly disagree 13% 14% 9% 19% 13% 8% 14% Total I had the time to support relatives and those of importance to the patient (n. 27,448) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 8% 6% 8% 3% 9% 8% 6% Agree 28% 24% 20% 6% 30% 26% 25% Neither agree nor disagree 30% 28% 45% 58% 28% 35% 29% Disagree 27% 33% 20% 18% 28% 23% 31% Strongly disagree 7% 9% 7% 16% 7% 8% 8% Total I felt satisfied with the quality of care I was able to provide (n. 27,513) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 10% 10% 18% 11% 14% 14% 11% Agree 33% 32% 37% 27% 40% 40% 33% Neither agree nor disagree 20% 21% 18% 17% 18% 21% 20% Disagree 28% 30% 22% 35% 22% 20% 28% Strongly disagree 9% 8% 5% 11% 6% 5% 8% Total 14

15 ROYAL COLLEGE OF NURSING I was concerned about the skill mix (n. 27,481) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 15% 16% 12% 23% 10% 20% 15% Agree 31% 31% 24% 26% 26% 28% 30% Neither agree nor disagree 24% 22% 23% 22% 26% 23% 23% Disagree 23% 24% 27% 23% 28% 22% 25% Strongly disagree 7% 7% 14% 6% 10% 8% 7% Total I was able to provide the quality of care that I would want to receive as a patient (n. 27,491) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 9% 9% 17% 10% 15% 15% 10% Agree 26% 28% 32% 24% 37% 37% 29% Neither agree nor disagree 20% 19% 22% 18% 17% 19% 19% Disagree 33% 34% 21% 34% 24% 22% 32% Strongly disagree 12% 10% 8% 14% 7% 7% 10% Total Due to the lack of time, I had to leave necessary care undone (n. 27,502) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 35% 34% 33% 24% 37% 39% 7% Agree 7% 7% 7% 14% 7% 6% 28% Neither agree nor disagree 21% 19% 21% 21% 18% 24% 19% Disagree 26% 30% 21% 31% 24% 18% 35% Strongly disagree 11% 9% 18% 9% 13% 13% 10% Total 15

16 STAFFING FOR SAFE AND EFFECTIVE CARE I was too busy to provide the care I would like (n. 27,452) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 17% % 20% 13% 13% 17% Agree 39% 41% 29% 43% 34% 29% 40% Neither agree nor disagree 15% 14% 17% 14% 16% 22% 15% Disagree 21% 20% 26% 18% 27% 27% 21% Strongly disagree 8% 7% 14% 5% 10% 9% 7% Total Too much of my time was spent on non-nursing duties (n. 27,500) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 20% 16% 21% 18% 22% 12% 18% Agree 38% 37% 34% 33% 36% 29% 37% Neither agree nor disagree 20% 23% 23% 27% 20% 25% 22% Disagree 18% 19% 14% 19% 18% 26% 19% Strongly disagree 4% 4% 8% 3% 5% 8% 4% Total I was concerned that support staff were being expected to perform the duties of registered staff without appropriate supervision (n. 27,390) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 7% 7% 9% 14% 7% 8% 7% Agree 21% 20% 13% 23% 18% 18% 20% Neither agree nor disagree 17% 21% 28% 29% 26% 25% 21% Disagree 41% 39% 32% 22% 35% 29% 38% Strongly disagree 14% 14% 18% 12% 14% 20% 14% Total 16

17 ROYAL COLLEGE OF NURSING I was provided with the appropriate supervision and support (n. 27,424) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 7% 7% 10% 6% 8% 8% 7% Agree 23% 28% 21% 18% 28% 22% 27% Neither agree nor disagree 30% 30% 33% 20% 30% 30% 30% Disagree 27% 26% 26% 30% 23% 26% 25% Strongly disagree 13% 10% 10% 25% 10% 14% 10% Total I felt fulfilled (n. 26,786) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 6% 4% 7% 6% 6% 6% 5% Agree 21% 20% 25% 15% 24% 20% 21% Neither agree nor disagree 27% 25% 27% 26% 25% 24% 25% Disagree 32% 37% 28% 33% 33% 35% 36% Strongly disagree 14% 13% 13% 21% 11% 15% 13% Total I felt demoralised (n. 26,699) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 14% 15% 16% 24% 15% 18% 15% Agree 29% 30% 28% 25% 29% 32% 29% Neither agree nor disagree 23% 22% 21% 23% 22% 20% 22% Disagree 25% 25% 25% 19% 26% 22% 25% Strongly disagree 10% 7% 10% 9% 9% 9% 8% Total 17

18 STAFFING FOR SAFE AND EFFECTIVE CARE I felt upset/sad that I could not provide the level of care I had wanted (n. 26,786) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Strongly agree 19% 22% 15% 22% 17% 16% 21% Agree 33% 34% 24% 38% 27% 30% 32% Neither agree nor disagree 18% 18% 25% 20% 21% 20% 18% Disagree 20% 20% 23% 14% 25% 23% 21% Strongly disagree 9% 7% 13% 6% 9% 11% 8% Total Thinking more generally, if there are not enough staff, or it patient care is compromised, have you been able to raise a concern? (n. 26,871) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) No 19% 21% 17% 22% 18% 17% 20% Not applicable 9% 7% 12% 8% 9% 6% 7% Yes 72% 72% 71% 70% 73% 77% 72% Total When you raised a concern, was any action taken to try to address the issue? (n. 19,184) A care home A hospital Other Prison/police custody The community Urgent and emergency care (non-hospital) Don t know 18% 19% 19% 24% 18% 20% 19% No 40% 45% 43% 50% 43% 42% 44% Yes 42% 36% 36% 26% 39% 38% 37% Total 18

19 ROYAL COLLEGE OF NURSING Appendix 3 - Free text responses to perception and wellbeing questions Safe and effective care survey free text responses on perceptions and wellbeing The themes presented in this report are based on exploration of free text information entered by 17, 819 respondents. These entries provide examples and further detail related to the closed ended questions about perceptions and wellbeing. Respondents indicated whether or not they gave permission for their entries to be published. In our September 2017 report, we published a selection of illustrative quotes. To further bring to life the experiences described within this large data set, we now present here entries referring specifically to examples of impact of staffing on patient and staff, for which permission was given to publish. These represent responses from across the UK and are presented by main setting indicated by the respondent. A hospital, such as adult acute, children s acute, mental health inpatient etc. Community-based services, such general practice, district nursing team, hospice, school nursing etc. Urgent and emergency services (non-hospital, for example call centre, walk-in centre, home visits) Prison and police custody settings Other services, including specialist clinics, forensic mental health services, ambulance services, assessment centres, occupational health, children and adolescents mental health services (CAMHs), respite services, pharmacy, supported living etc. 19

20 STAFFING FOR SAFE AND EFFECTIVE CARE 1 Hospital I ve only been qualified seven months and I ve never worked a shift where the staffing levels are adequate. Someone has usually always phoned in sick, or there s been a family issue. Quite often the shortage has just been down to poor planning. I don t feel safe or supported. The patients can tell we re short staffed, they ve mentioned it to management in person and they ve mentioned it on the friends and family questionnaire at the end of their admission. A lot of patients, both young and old feel they are troubling us, as they ve witnessed us buzzing around at a 100 miles an hour and won t ask for a drink or the toilet until we approach them. Sometimes this can be hours. One newly qualified nurse and two HCAs is not safe or practical for 15 patients!! The whole team on my ward feel demoralised particularly the nursing staff that shoulder all the responsibility as there is so much pressure on the system at the moment. It is breeding an atmosphere of discontent and is driving staff to leave which in turn creates strain on existing staff to cover all the antisocial shifts which impact on their family and quality of life. Nurses feel undervalued and under paid for the complexity and pressure of the job. I now find myself regularly feeling that I ve not been able to provide safe let alone quality care to my patients. This is completely inappropriate and unacceptable, and to be put in a position where I feel as though I am harming patients due to a systemic lack of concern for safe staffing levels is pushing me towards seriously considering a new career. This must stop. This is scandalous, cruel to both patients and staff and quite frankly dangerous! We are significantly bottom heavy in terms of skill mix which means these junior colleagues are getting pushed into progressing before they are ready, which is destroying them as people, leaving patients in unsafe settings because these nurses simply lack experience to be able to adequately perform the roles expected of them. These nurses then leave and our staffing becomes worse and worse. At times, patient care has been compromised and my concerns for my registration and mental health have been higher than at any other time in my career. I was frequently completing paperwork after handover as there was not enough time in the shift to stop attending to direct patient care and complete it. As a student in my final year, I am concerned with the time spent getting up to scratch ready to qualify due to staffing levels are so low. I am regularly left doing tasks such as medications without proper supervision. I am constantly finding someone to double check and countersign my meds as I will not do it without. In theatre the difficulty of poor staffing levels mean that patients could be cancelled. Though not compromising care it is awful when this happens. We also have great difficulty in teaching junior staff, putting extra pressure on the more experienced and I feel a sense of failure towards the junior staff with regard to their training needs. As Matron I am aware of all staffing issues which are taken to the bed meeting twice a day. No ward is left unsafe because we adjust and move staff where necessary. However, working in a very specialised hospital it is difficult to ensure speciality skilled staff stay in their own areas. Some nurses find this very stressful and get fed up with being moved. Over the last 30 years in the NHS, I have seen a rapid decline in nursing numbers and this scares me. I fill in regular incident reports for unsafe staffing levels, none of which I ve ever been spoken to about. Vital medication was missed during this shift as I had too much on my mind, I missed breaks and I went home feeling hungry, tired and like a failure. I am looking for a new job leaving nursing. I work on a busy respiratory ward, often we get very unwell patients on the ward who really should be in ICU. I am a sister and am always in charge, coordinating and I have nine patients to look after. I am expected to look after those patients, attend a ward round, and support junior staff and discharges. I cannot remember the last time I left on time, I always stay at least 30 minutes late to finish work/writing. Lack of medical staff is also an issue, we often only have an FY1 on the ward who often lack the experience to deal with such unwell patients. Weekend medical staffing is awful, doctors are so busy with unwell patients in A&E that ward patient care is 20

21 ROYAL COLLEGE OF NURSING compromised, e.g. today I had a patient who was end of life and needed a syringe driver, we were unable to start it for several hours as no doctors were free to prescribe it. Newly qualified staff often cry during shifts due to stress and a fear of compromising patient care. I genuinely feel like I ve been put in positions where my pin is at risk due to unsafe staffing levels. Not enough time to talk to patients. Repetitive answers in paperwork because it has to be done, and not enough time to do it properly. Drugs nearly always late, and an increased risk of errors because you have to do other things such as give out commodes at the same time as doing drug rounds. Reduced staffing puts you at risk of losing your pin, because management will not back you up if you make a mistake due to poor staffing. Working in a busy oncology clinic is demanding when we are fully staffed. When there is poor staffing levels, morale drops and patients don t get the care and attention they deserve. Nurses are expected to carry out the same work load and tasks as they do when they are fully staffed. I leave work feeling drained and stressed. Due to staff mix, the staffing during my last shift was all junior nurses, In order to ensure that my patients were provided with the best care I could give them, I cut my break short. As a mental health Nurse one of my last shifts had four patients on continuous observations due to their mental state and there was six members staff of on duty, staff did not receive their correct breaks and patients were left frustrated as their needs could not be met in a timely manner! I personally feel that patients are not receiving the care they should be due to staffing levels and I feel that staff are stressed, over-worked and under appreciated by the trust! I am perennially impressed by the resilience I see in the nurse population. As a nurse with 38 years experience, I generally enjoy what I do. I work bank for the unit I used to manage out of a sense of loyalty to the service that needs help. I work from a position as a bank nurse where I know that I will be in a short staffing scenario as the unit will not call me if they have their full compliment. I also work a small amount of agency in other hospitals and again this is always because they are short staffed. Nurses do not generally express their concerns to management as they feel the managers are hamstrung by policy devised by an intransigent, indifferent government that will hold us professionally to account but fail to treat us professionally. Recently our staffing levels have improved. This is the first time in the last two to three years we ve had our staffing compliment. This improves the care we can safely deliver efficiency and effectiveness. Students and new staff have more learning opportunities with their mentor. Staff can get their breaks and get off duty on time which all which improves staff morale. When staffing levels are low it impacts on the staff who are trying their best to give patients the best possible care. In my workplace we do lots of dressings and sometimes it seems like a conveyor belt to get the next patient seen and to treat the patient holistically rather than just changing a dressing. Our patients need our time also to convey their thoughts and feelings but sometimes the pressure to get patients in and out is overwhelming and at the end of a busy shift we are left with feeling we should have done more. As part of the management structure but at the bottom tier you feel very vulnerable. You know staffing levels are not good, you try to move staff, to cover a shift from another area to minimise the risk but you are in turn leaving two areas short. There are no staff in the recruitment pool but you are not permitted to close ward beds regardless of the number of suitably skilled staff. In fact you are being told by senior management that you have to put extra patients into the ward in corridors or squeeze them into a bay as extra. We have had staffing levels at crisis for months, vacancies for nursing posts have not been advertised quickly, delays up to a year There are shifts where patient care is compromised, the phrase accident waiting to happen is used daily. Management have only begun discussing how to support our units staffing, nothing has been done yet. Morale is at an all-time low. We are losing staff quicker than we are gaining. The impact that staffing levels has had on myself is, feeling more pressurised when being left in charge of a ward when you regard yourself as being a junior member of staff, crying when leaving 21